low anterior resection with colostomy but NO anastomosis


Delaware, OH
Best answers
Hello everyone -

I need assistance.
Patient had a intestinal fistula that attached to the lower abdominal wall and was leaking stool through the patient's pannus. Patient with diverticulitis. My doc resects the tract from the abdomen. There are several pelvic and abdominal abscesses he drains too. He staples shut the rectum and then creates a colostomy with the distal end of the colon. He does NOT do an anastomosis due to possible sepsis and peritonitis. I can't find a code that quite explains this situation.
Right now... I am leaning towards 44143 and 49084 (because he does do a washout as well). I also thought of adding a 22 modifier to cover all the abscess work he did and this patient was severely obese which caused the procedure to take longer and required extra staff.
It seems when they are in the lower anterior area that 44146 fits better but like I said, he did not do an anastomosis. 44146 also happens to be the code the doc wants too.

Then I was also tossing around 44640 (intestinal fistula closure) with 44320 (skin level colostomy) however... 44640 says they reattach the bowel ends and he does not do that.

Any help on which direction I should go, would be great.
I understand I did not attach the op report.